Professional Documents
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MMR (Measles, Mumps, Rubella) – 2 doses of MMR vaccine or two (2) doses of Measles, two (2) doses of Mumps and (1) dose of Rubella;
or serologic proof of immunity for Measles, Mumps and/or Rubella
Hepatitis B Vaccination --3 doses of vaccine followed by a QUANTITATIVE Hepatitis B Surface Antibody (titer) preferably drawn 4-8 weeks after 3rd dose.
If negative, complete a second Hepatitis B series followed by a repeat titer. If Hepatitis B Surface Antibody is negative after a secondary series, additional testing
including Hepatitis B Surface Antigen should be performed. See: http://www.cdc.gov/mmwr/pdf/rr/rr6210.pdf for more information.
Documentation of Chronic Active Hepatitis B is for rotation assignments and counseling purposes only.
Date
Hepatitis B Vaccine Dose #1 ___/___/_____
Tetanus-diphtheria-pertussis – One (1) dose of adult Tdap. If last Tdap is more than 10 years old, provide date of last Td and Tdap
Date
Tdap Vaccine (Adacel, Boostrix, etc) ___/___/_____
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TUBERCULOSIS SCREENING – Results of last (2) TSTs (PPDs) or (1) IGRA blood test are required regardless of prior BCG
status. If you have a history of a positive TST (PPD)>10mm or IGRA please supply information regarding any evaluation and/or
treatment below. You only need to complete ONE section.
Skin test or IGRA results should not expire during proposed elective rotation dates
or
must be updated with the receiving institution prior to rotation.
Tuberculin Screening History
Section A Date Placed Date Read Reading Interpretation
Negative Skin or
Blood Test TST #3 ___/___/____ ___/___/____ ____ mm Pos Neg Equiv
History
Date Result
Please complete one TB section only
Date Result
Section C Date
Date of Diagnosis ___/___/___
Date of Treatment Completed ___/___/____ Copy Attached
History of Active
Tuberculosis Date of Last Annual TB Symptom Questionnaire
(if applicable) ___/___/____ Copy Attached
© 2015 AAMC. May be reproduced and distributed in its entirety, no modification, with attribution. Page 2 of 3
Additional Information:
Printed Name:
Office Use Only
Title:
Address Line 1:
Address Line 2:
City:
State:
Zip:
Email Contact:
*Sources:
1. Hepatitis B In: Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine‐Preventable Diseases. Hamborsky J, Kroger A, Wolfe S, eds.
13th ed. Washington D.C. Public Health Foundation, 2015
2. Immunization of Health‐Care Personnel: Recommendations of the Advisory Committee on Immunization Practices (ACIP), MMWR, Vol 60(7):1‐45
3. CDC Guidance for Evaluating Health‐Care Personnel for Hepatitis B Virus Protection and for Administering Postexposure Management, MMWR, Vol 62(RR10):1‐19
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